The nurse obtains the following vital signs on a 1-year-old ...

[CBme]

The nurse obtains the following vital signs on a 1-year-old childT: 37.8C rectal; P: 76; R: 24; BP: 92/60. The nurse evaluates vital signs as which of the following?
 
  1. Vital signs are within normal range.
  2. The client is hypothermic.
  3. The client is hypertensive, and the physician should be notified.
  4. The pulse is borderline low, and requires further assessment.

Question 2

The nurse recognizes that pain assessment is an important aspect of all nursing assessments. Clients might be reluctant to self-report pain because of: Standard Text: Select all that apply.
 
  1. A fear of shots.
  2. A belief that expressions of pain reveal weakness.
  3. Not wanting to disturb staff.
  4. A fear of addiction.
  5. A fear that the nurse won't believe the pain reported.

[kxciann]

Answer to Question 1

4
Rationale: The client's pulse is borderline low, and further assessment is needed, as this could be normal for the child, or the child could have a problem. Remaining vital signs are within normal limits.

Answer to Question 2

1,2,3,4
Rationale: Children in particular might fear the injectable rout of analgesic administration.